- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,513.56
| Professional | | $1,202.26 | $1,202.26 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1.00
| Facility | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $2,691.53
| Facility | | $1,202.26 | $1,737.80 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,862.09 / $3,715.35
| Facility | | $1,096.48 | $1,862.09 | $3,715.35 |